Invasive proposed biopsy of up to 20 cores - normal?

[pdonaldson54]

I recently had a PSA test which showed a PSA of 19.1. As this was high, my doctor referred me to a urologist for investigation, I insisted on having an MRI done before I would agree to a biopsy as I don’t want to undergo a biopsy if I don’t have to. So I had the MRI, which came back three days ago showing:

* 1 area with restricted diffusion and abnormal signal
* 1 area with restricted diffusion and abnormal signal ADC
* 2 areas with a PI–RADS 5 (very likely cancer)
* 1 area with a PI-RADS 4 (very likely cancer)

Originally, my uro wanted to do a 12 core random biopsy (this was before I insisted on the MRI), but now he wants to do two cores for each suspicious area AND the original 12 core random biopsy.

He said that the MRI could have missed some areas that may contain cancer and so this is why he wants to do 12 random cores plus two biopsies in each of the areas of concern. That's going to be 18 to 20 biopsy cores! Does that sound like a lot? Are there health issues with doing such an extensive biopsy (damaging the prostate - does it recover?) or is it just for the best?

I don’t like invasive treatment and would prefer to minimise it if possible, but I understand we are talking about a potentially very aggressive cancer here, so if I have to undergo it I will.

[professoreden]

Hi, thanks for the questions and well done for sticking to your guns and insisting on a pre-biopsy MRI scan. This is what I would always recommend as it makes the biopsy process more accurate.

Your PSA is very high at 19.1. You don't state your age but assuming you are in your 60s the upper acceptable limit for you is 4.5, so it's about 4 times normal. The PIRADS score assigned by the Radiologist reporting your MRI scan predicts the likelihood of prostate cancer being present in that particular area based on the MRI appearances. The likelihood of finding prostate cancer is approximately 10 % in a PIRADS 1 lesion and 90% in a PIRADS 5 lesion, with increasing scores correlating well with an increasing risk of detecting prostate cancer.

Your urologist has recommended an MRI-targeted prostate biopsy, which is very sensible, along with systematic biopsy of areas which look normal on the scan. This is important because 10-20% of prostate cancers can look normal on an MRI scan and it is important to have a clear idea of the distribution of the cancer within the prostate when planning nerve-preserving surgery. Only prostate biopsy can definitively give this information.

I know that 18-20 biopsy cores sounds like a lot but I imagine that your urologist plans to do this with you asleep as a day case using a transperineal (i.e. not through the rectum) approach to reduce discomfort to you and the risk of infection. It sounds as though you have been given excellent advice and I completely agree with your urologist.